The other side of the speculumBrent Thoma Third-year medical student at the University of Saskatchewan

I know women hate Pap smears. I wouldn’t enjoy a complete stranger shoving foreign objects into my body either. But here’s a little known fact: men, especially young men, hate performing them. I know the first thing that pops into a woman’s mind as she spreads her legs is not going to be "I wonder if he’s uncomfortable," but please hear out the guy on the other side of the speculum—I detest this procedure more than you do. Put yourself in my shoes for a second. You’re a 24-year-old male medical student in your second week at the clinic. It’s been a great day—low back pain, otitis media, pharyngitis; you’re really getting the hang of this family med thing. And then you get to the next room and face your worst nightmare: [Women’s name]—Complete.

Your first instinct is to be professional: pretend you didn’t notice the chart and hope someone else sees the patient while you’re hiding in the bathroom. Unfortunately, today your luck fails and it’s all up to you. So, you enter the room and note the inevitable inaudible groan from the hapless female. There are a number of variations on this groan, depending on the patient’s age: The young teenager: "Aghh!! A boy!?!?!" followed by immediately looking at the ground. In the meantime, you thank God that she doesn’t need a Pap smear.

The 30- to 45-year-old woman: "Ugh, a student ... and a male student! Just my luck, he probably hasn’t even found a vagina yet."

The > 45-year-old woman: "Hahaha, oh, a young buck!"

If this isn’t bad enough, it gets even more awkward if they came in for a physical only because they didn’t want to tell the nurse that they have "something" going on "down there." Suffice to say, herpetic lesions, warts, yeast infections, and week-old tampons are not what get me up in the morning. All is not lost yet, however. You still have the interview to "build rapport." Personally, I have yet to build enough "rapport" with a woman after knowing her for 10 minutes to stick anything in her vagina. And yet, you do your best to build this mythical "rapport" anyway. By the time you’re done the interview, you’ve drawn a complete pedigree, discussed what psychiatric ailments might be more likely to affect her as a middle child, taken her blood pressure (regular and orthostatic), and inquired about the health of her ex-husband. You know more about her than her mother, yet you still don’t feel ready. So, on the way to get your preceptor you frantically search through your PDA to find an evidence-based reason why this woman simply doesn’t need a Pap smear. Inevitably, you end up back in the room with your preceptor, who has a 2-minute chat with the patient (to build rapport, you know) before getting out the speculum. The next trick is to stand quietly in the corner of the exam room, writing frantically while he gets things ready. This technique relies on the attending’s kindness: if he is merciful, your presence will be forgotten and you’ll escape the perils of the vagina once again. If not ... it’s show time. Finally, the moment you’ve managed to avoid for the entirety of medical school arrives. Apparently the trick is to keep the patient comfortable by explaining the procedure to them as you do it. This provides an unfortunate opportunity for your voice to crack while saying, "Just let your legs fall apart." The attendings seem to have mastered saying these things with the tone used in those Philadelphia Cream Cheese heaven commercials. Unfortunately for me, I just can’t say "Now I’m going to insert the speculum into your vagina" in that tone—no matter how many times I practise in front of the mirror. You’d think that from there, things would get easier. Unfortunately, there is a huge variety of female anatomy. There are women of all shapes, sizes, and grooming preferences. This presents one final problem: what if you can’t find the cervix? If you’ve avoided feeling awkward up to this point, imagine yourself frantically moving the speculum around like a searchlight while hoping to God you don’t have to say, "Uhhh, I can’t find it." So there you have it—what’s going on in the head of the person on the other side of the speculum. For anyone who will soon learn to perform this horrid ritual, I recommend that you talk yourself through it before you try to talk a patient through it (trust me, you don’t want to say "it" instead of "speculum"); learn to give instructions in the Philadelphia-cheese-lady voice; never, ever compliment anything down there; and pretend you see vaginas every day. And for all the women out there who are lucky enough to be the subject for someone’s first Pap smear, try to remember that we’re just as uncomfortable as you are. My first attempt actually laughed through the procedure because I was so "cute and awkward."

Midwife tells pregnant women to take the pain

Leading midwife warns of epidural epidemic Says women need to take
the pain more 'Women want to avoid pain, but should be prepared to withstand
it'

Tracey Spicer: Give me the bloody drugs

WOMEN should embrace the full pain of childbirth to bond with their babies
instead of resorting to anaesthetic drugs, a leading male midwife has said.

UK
professor Dr Denis Walsh said the pain of labour should be considered a
"rite of passage" and a "purposeful, useful thing".

The pain prepares women for the responsibilities of motherhood, he wrote in an
international journal published yesterday.

Eleanor Page of Surry Hills Posted at 4:13 PM July 17, 2009

It wasn't "long ago that women regularly died in childbirth" they
do every day, all over the world still. Dr Dennis Walsh needs to spend some
time in Mali and Afghanistan and
see the results of natural childbirth for himself. Or perhaps he would like to
visit a more properous country like Iraq where caesarians are available
in an emergency, but there's no epidural drugs or anathesia for it. Then he can
pull his head out of his a*se and realise that for us human bipeds the last
stage of reproduction is high risk compared to four legged mammals. It is the
trade off for our large intelligent brains and big headed babies and our
ability to walk on two legs by balancing on a narrow upright pelvis.
Fortunately that intelligence and evolution has allowed us to find ways to
reduce the risks and pain involved in human childbirth, but only the fortunate
minority of women on this planet benefit from it. For him to suggest it be
taken away to make us somehow better mothers is just obscene.

Mary Shelley Had NO IDEA

I really,
really wish that yesterday could have been one of those days that I posted
something profound and/or heartfelt and/or intellectually stimulating. Because,
god knows, I don’t want to come off as just another stupid, narcissistic
mommyblogger who suffers from some terrible delusion that people want to read
about what she thinks or – gods forbid – about her children or her depression
or whatever trials and tribulations related to motherhood that she thinks –
wrongly – might interest anyone other than herself and possibly maybe four or
five other similarly deluded women who’ve gone off their meds. But, dammit, I
went and blew the wad on thoughtfulness last week, and then went and spent my
remaining brain cells railing against misogyny yesterday, so whaddya know?
You’re just going to have make do with my vagina.

Nope. Not
a bunny, not a reindeer, not Glory Hole with Chewing Gum (Triple J Truck
Stop- Yuma, AZ, 2003), not The Wind In My Vagina, not a minimalist
profile of a very sad donkey (all actual suggestions, please to go read and pee
yourself.) No: these are my hideous nethers.

That was a
picture of my lady parts, artfully sketched by my doctor. Although I suppose
that we might say that it was less art than it was artifact of doctorglyphics:
it was an attempt by my doctor to explain to me how it was that yes, things
can get worse than a fourth-degree tear sustained in an emergency delivery! That
fourth-degree tear can end up with a botched repair because the surgery was
performed so hastily and under such trying circumstances. Yep: botched repair.
Sloppy stitchwork. Sewn up wrong. Ripped and slashed in birth and then stitched
up roughly into some hideous, half-healed, scarred-up mess. Monster-nethers.
Frankenvulva.

I don’t know
about you, but I don’t recall anybody ever telling me, ever, that the vaginal
delivery of a baby could result in varying degrees of genital mutilation.
Which, you know, is probably not surprising, given that stories about ripped
anal-sphincter muscles just wouldn’t do much for the sales of those glossy
pregnancy magazines. And I can’t blame my mother for not telling me, nor the
Canadian education system for neglecting to cover the subject of SEX ORGAN
DAMAGE in middle school sex-ed. Because, yes, that would probably have scarred
me for life, and my parents and my teachers and the architects of sex-education
programming in the province
of British Columbia knew
it. So, it’s no wonder, then, that I had no way of knowing that after giving
birth I would, indeed, end up scarred for life.

Of course – of
course – it was all worth it, the miraculous gift of my beautiful son – my
beautiful progeny – being more than ample recompense for the damage sustained
to my birthing parts, which did, after all, just do the job that Nature
intended them to do (not, however, particularly effectively. JUST SAYIN) yadda
yadda blah. But still. My joy at the gift that is my son does not in any
way mitigate my frustration with ongoing nether-discomfort, my distress at the
possibility that I will go through the rest of my life with a Frankenvulva and
my determination to get it fixed and put the damage behind me (figuratively.
The damage is, after all, literally behind me, and, also, below me. But
whatever. Details, schmetails.) So. Is he going to hear about this at his
wedding? HELL YES.

(Not really.
Not unless I’m drunk, that is. Which is a possibility, I suppose. A good one.)

(Anyone who
had any illusions about me being some kind of gentle and gracious soul is
really, really disappointed right now, I guessing.)

Did your clitoris hurt? I know this is kind of a strange question but mine
really hurts when I move in certain ways and when I pee... Did anyone else get
this? If so, what is it?

Yes. Mine did severly. I called my doctor and she said since I delivered
vaginally (which I am assuming you did) sometimes the baby pushes really hard
on this area and can make it irritated. Plus all the wiping with toilet paper
and pads and such can make it worse. I would try using witch-hazel pads to wipe
and leaving on your pad to releive the pain.

I know the other ladies answered the same but yes, it seems to be pretty
common with a vaginal birth. Mine hurt for several weeks. I don't remember
exactly how long but it was at least 8 or 9.

Yes it did. When I peed and when I squeezed (like I was cutting off my pee
stream) I'm 9 weeks post partum and it still hurts but I went to the doctor at
6 weeks and she said it was more than likely trauma from pushing because I
didn't have a UTI or anything.

Poor women less likely to get epidurals

Tue Jan 26, 2010 3:15pm EST

NEW YORK (Reuters Health) - Even
under Canada's
system of universal healthcare, low-income women are less likely than their
wealthier counterparts to receive epidural pain relief during childbirth, a new
study finds.

The findings mirror those of studies from the U.S. and other countries, and
suggest that factors other than health insurance are at work, according to the
researchers.

An epidural involves injecting pain medication through a catheter into the
lower spine, and is considered the most effective way to relieve pain during
childbirth. But studies have suggested that socioeconomics -- including income,
race or education -- sway a woman's likelihood of having an epidural.

For the new study, reported in the American Journal of Obstetrics &
Gynecology, researchers looked at epidural use among more than 200,000 Ontario women who gave
birth between 2004 and 2006.

They found that the one-fifth of women from the poorest neighborhoods in the
study were 41 percent less likely to have epidural pain relief than the
one-fifth of women from the wealthiest neighborhoods. There was a similar
discrepancy between the least educated and most educated women.

The effects of income and education were seen even though the researchers
accounted for factors like health problems in the mother and pregnancy
complications -- which can hinder the use of epidurals.

Moreover, given Canada's
universal health system, the findings suggest that factors other than insurance
coverage are important, say the researchers, led by Ning Liu of the University of Ottawa.

"We argue that noneconomic maternal characteristics contribute much to
the disparity," Liu's team writes.

A woman's education level, for instance, could affect her willingness to
have an epidural, the researchers note. Women with more education, they write,
may know more about epidurals and be more open to having one.

Race, ethnicity and cultural views may also play a role, according to Liu's
team. There is evidence, for example, that women from Asia
often feel that childbirth pain is natural and, therefore, they should
"tolerate" it.

In addition, research in the U.S.
has found that African Americans are less accepting of epidurals than whites.

Studies have also found that lower-income women are less likely to attend
prenatal classes -- a place where they would learn about the different types of
pain relief available during childbirth.

The findings are based on the childbirth records of 220,814 Ontario women. Of women
in the poorest neighborhoods in the province, 56 percent had an epidural,
compared with almost 69 percent of women in the wealthiest neighborhoods.

Education appeared to make an even bigger difference. Among the one-fifth of
women with the lowest education levels, half had an epidural. That compared
with roughly 71 percent of the one-fifth of women with the highest education
levels.

Those disparities were least apparent at large, academic medical centers,
and most significant at small community hospitals, the researchers found.

Epidurals, in general, were used less often at small hospitals -- which is
not surprising, according to Liu's team, since that trend has been documented
in other studies. But it is not clear why income- and education-related
disparities were greatest at small community hospitals.

They call for more research into the reasons for lower epidural rates among
low-income women.

Nigel Hawkes: A bad case of bias against Caesareans

Behind the numbers

Saturday, 30 January 2010

The World Health Organisation
disapproves of over-medicalising birth,

But it isn't going to advance its case by publishing
evidence as unconvincing as that in a recent Lancet paper. The 23 authors
concluded that a mother who opts for a Caesarean without a good
medical reason is 2.7 times as likely to suffer death or complications as a mother who
completes a normal birth.

That's enough to put the fear of God into the "too posh
to push" brigade, which I suspect was the authors' intention.
Unfortunately, the conclusion is in no way supported by the evidence presented.
The team, from the WHO's global survey on maternal and perinatal health
research group, looked at medical records from 107,950 births in Asia. Of these, just 1,515 were Caesareans chosen in
advance of birth with no medical indication to justify them. Almost all of them
were in China.

So how many women died? None. How many suffered
complications? Eight: five needed treatment in an intensive care unit (ICU),
and three needed a blood transfusion. The risks for women who completed a
normal birth were significantly higher. One in a thousand died, five times as
many required a blood transfusion, and twice as many were admitted to an ICU.

Overall, if deaths and complications are added up to make a
"Maternal mortality and morbidity index", risks to mothers in the
Caesarean group were 60 per cent lower than in the normal birth group.

So how, from this, does the team conclude that risks to
mothers who have Caesareans are actually 2.7 times greater? There's a hefty
difference between 60 per cent smaller and 270 per cent greater, but
statistical manipulation is a powerful tool.

The team achieves this transformation by correcting for a
range of risk factors. If the Caesarean mothers were an especially low-risk
group, then it is possible that such a correction could narrow the gap or even
eliminate it. The adjustments in this case included such things as age,
education, previous medical disorders, high blood pressure, and so on.

It's easy enough to work out how much lower the risks must
have been to make such a huge correction to the raw data. The women who had
Caesareans must have had only one seventh as much baseline risk as those who
had a natural birth in order to make it work – and that's highly
implausible.

Nowhere in this paper does the team comment on the
remarkable transformation of the figures. But they do say: "The most
important finding of the survey is the increased risk of maternal mortality and
severe morbidity which was analysed as a composite outcome in women who undergo
Caesarean section with no medical indication."

Did none of the 23 think this an odd conclusion to have
reached? Did no one check the arithmetic in the tables, which are full of
errors? The Lancet is a distinguished journal – were its referees asleep?

Connoisseurs of the bending over backwards that medical
authors do to get the "right" answer call it White Hat bias, after
old-style Westerns where the hero always wore a white hat. This is a classic
example. Policy says Caesareans are bad, so the evidence had better prove it.

And what about the babies? Those born by elective Caesarean
without medical indications were seven times less likely to suffer death or
complications (raw data) or less than half as likely if you believe the
corrected data. Understandably, the authors don't make much of this.